HISTORY AND PHYSICAL EXAMINATION Patient Name: Patrick Platt Patient ID: 771033 Room No: 560 Date of Admission: 08/30/—- Admitting Physician: William Payne, MD Admitting Diagnosis: Rule out fracture of left arm. CHIEF COMPLAINT: Pain and swelling, left upper arm. HISTORY OF PRESENT ILLNESS: The patient is an elderly male, who fell four days prior to admission.
He noted immediate pain and swelling in the area just above his left elbow. He presented to the emergency room for treatment. PAST HISTORY: Past illnesses include whooping cough as a child.
Tonsillectomy in the past. No known allergies to medications. FAMILY HISTORY: No hereditary disorders noted. Mother and father are deceased. Two brothers are alive and well. One sister has adult-onset diabetes mellitus. SOCIAL HISTORY: The patient is married and has two children. His wife does not work outside the home. (No mention of tobacco or alcohol use). PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished male who appears to be in moderate distress with pain and swelling in the upper left arm.
Vital signs: Blood pressure 140/90, temperature 98. 3 degrees Fahrenheit, pulse 97, respiration 18. HEENT: Head normal, no lesions, Eyes, arcus senilis, both eyes. Ears, impacted cerumen, left ear. Nose, clear. Mouth, dentures fit well, no lesions. NECK: Normal range of motion in all directions. (Continued) HISTORY AND PHYSICAL EXAMINATION Patient Name: Patrick Platt Patient ID: 771033 Date of Admission: 08/30/—- Page 2 INTEGUMENTARY: Psoriatic lesion, right thigh, approximately 1 mm in diameter.
CHEST: Clear breath sounds bilaterally. No rales or rhonchi noted. HEART: Normal sinus rhythm. There is a holosystolic murmur. No friction rubs noted. ABDOMEN: Normal bowel sounds. Liver, kidneys, and spleen are normal to palpation. GENITALIA: Tests normally descended bilaterally. RECTAL: Prostate 2+ and benign. EXTREMITIES: Pain and swelling noted above the left elbow, other upper extremities normal. No cyanosis or clubbing. The legs demonstrate 2+ pitting edema to the knees.
NEUROLOGIC: Crainial nerves II through XII intact, memory intact, sensation intact to light touch. ASSESSMENT AND PLAN: The patient was sent for plain film of the left arm, which revealed a fracture of the left humerus. The fracture was reduced in the emergency room. X-ray revealed anatomic alignment. He was released to home with a prescription for a nonsteroidal anti-inflammatory and instructions to elevate his arm. He will follow up in the office in three days. PROGNOSIS: Good. _________________________ William Payne, MD WM:R D:08/30/—- T:09/01/—-